Walter Vincken

Obstructive and restrictive spirometric patterns: fixed cut-offs for FEV1/FEV6 and FEV6

The purpose of this study was to determine fixed cut-off points for forced expiratory volume in one second (FEV1)/FEV6 and FEV6 as an alternative for FEV1/forced vital capacity (FVC) and FVC in the detection of obstructive and restrictive spirometric patterns, respectively. For the study, a total of 11,676 spirometric examinations, which took place on Caucasian subjects aged between 20–80 yrs, were analysed. Receiver–operator characteristic curves were used to determine the FEV1/FEV6 ratio and FEV6 value that corresponded to the optimal combination of sensitivity and specificity, compared with the commonly used fixed cut-off term for FEV1/FVC and FVC. The data from the current study indicate that FEV1/ FEV6 <73% and FEV6 <82% predicted can be used as a valid alternative for the FEV1/FVC <70% and FVC <80% pred cut-off points for the detection of obstruction and restriction, respectively. The statistical analysis demonstrated very good, overall, agreement between the two categorisation schemes. For the spirometric diagnosis of airway obstruction (prevalence of 45.9%), FEV1/FEV6 sensitivity and specificity were 94.4 and 93.3%, respectively; the positive and negative predictive values were 92.2 and 95.2%, respectively. For the spirometric detection of a restrictive pattern (prevalence of 14.9%), FEV6 sensitivity and specificity were 95.9 and 98.6%, respectively; the positive and negative predictive values were 92.2 and 99.3%, respectively. This study demonstrates that forced expiratory volume in one second/forced expiratory volume in six seconds <73% and forced expiratory volume in six seconds <82% predicted, can be used as valid alternatives to forced expiratory volume in one second/forced vital capacity <70% and forced vital capacity <80% predicted, as fixed cut-off terms for the detection of an obstructive or restrictive spirometric pattern in adults.

Successful Removal of a Massive Endobronchial Blood Clot by Means of Cryotherapy

Abstract: Because of its freezing characteristics, cryotherapy can be used to remove water containing foreign bodies. We describe a patient with massive hemoptysis in whom a large endobronchial blood clot was successfully removed using cryotherapy. This technique is probably the treatment of choice for removal of large clot from the airways.

Thoracoscopic T2-T3 sympathicolysis for essential hyperhidrosis in childhood: effects on pulmonary function.

Thoracoscopic T2‐T3 sympathicolysis (TS) is a minimally invasive treatment for patients suffering from severe, refractory essential hyperhidrosis (EH). TS has previously been shown to be safe and efficacious in children. In order to examine the effects of TS on respiratory function, pulmonary function tests (PFT) were performed prior to and 6 weeks and 6 months after TS in 12 children with EH (3 boys; mean age 12.8 ± 2.5 years). Small asymptomatic decreases in forced expiratory volume in one second (FEV1; −2%), forced expiratory flow after expiration of 75% of vital capacity (FEF75; −9.6%), total lung capacity (TLC; −1%), transfer factor for diffusion of carbon monoxide (TLCO; −7.6%), and transfer coefficient for diffusion of carbon monoxide (KCO; −1.5%) were observed 6 weeks after TS. These changes are comparable to those observed in adults but did not reach statistical significance in small children. In line with observations in adults, TLC (and TL,CO) returned to baseline values 6 months after TS, whereas FEV1, FEF75, and KCO remained at their 6‐week level. In conclusion, TS causes only small, statistically insignificant, and asymptomatic decreases in pulmonary function in children. TS can, therefore, be considered a safe treatment option in children suffering from severe, refractory EH. Pediatr Pulmonol. 1998; 26:262–264.

Dilemmas, confusion, and misconceptions related to small airways directed therapy

&NA; During the past decade, there has been increasing evidence that the small airways (ie, airways < 2 mm in internal diameter) contribute substantially to the pathophysiologic and clinical expression of asthma and COPD. The increased interest in small airways is, at least in part, a result of innovation in small‐particle aerosol formulations that better target the distal lung and also advanced physiologic methods of assessing small airway responses. Increasing the precision of drug deposition may improve targeting of specific diseases or receptor locations, decrease airway drug exposure and adverse effects, and thereby increase the efficiency and effectiveness of inhaled drug delivery. The availability of small‐particle aerosols of corticosteroids, bronchodilators, or their combination enables a higher total lung deposition and better peripheral lung penetration and provides added clinical benefit, compared with large‐particle aerosol treatment. However, a number of questions remain unanswered about the pragmatic approach relevant for clinicians to consider the role of small airways directed therapy in the day‐to‐day management of asthma and COPD. We thus have tried to clarify the dilemmas, confusion, and misconceptions related to small airways directed therapy. To this end, we have reviewed all studies on small‐particle aerosol therapy systematically to address the dilemmas, confusion, and misconceptions related to small airways directed therapy.

Cough, fatigue and fever.

A 37‐yr‐old male complained of a dry cough, fever, nocturnal sudation and dyspnoea. On lung auscultation, his general practitioner noticed right-sided expiratory wheezing and the diagnosis of tracheitis was withheld. Clarithromycin and a cough syrup were given and a slight amelioration was noticed, except for the persistence of dry cough. Bronchial hyperreactivity was suspected and a combination of budesonide and formoterol was added to the treatment. During the following 2 months, symptomatology varied; cough and dyspnoea were intermittently present until the patient started complaining of right thoracic pain and important fatigue. Fever re-appeared reaching 39°C, and, after consulting his general practitioner, cefuroxime and paracetamol were prescribed. Once again the fever disappeared, but a very invalidating cough with mucopurulent sputum, fatigue and chest pain persisted. After the antibiotic was stopped, fever reappeared and the patient was hospitalised. In his past history the patient was treated at the age of 12 yrs by immunotherapy for an allergic rhinitis caused by dust allergy. There was no particular familial history. He had never smoked and worked in an office. On clinical examination, the patient was pale, sweaty and thin. His blood pressure was 125/65, pulse 100·min−1 and temperature 38.7°C. On lung auscultation, breath sounds were diminished at the right lung base. Otherwise, physical examination was normal. Laboratory studies demonstrated a white blood cell count of 16×109·L−1, with 83% neutrophils, haemoglobin 131 g·L−1 …

Recurrent tracheal mass

In 1994 a 44-yr-old male was admitted for surgical resection of a hard, not painful, nodule which was believed to originate from the isthmus of the thyroid gland. He was known to have mild asthma, treated with inhaled corticosteroids and short-acting β2-agonists. His medical record revealed a smoking history of 20 pack-yrs. The patient denied any other symptoms, except the presence of the nodule. On physical examination a hard nodule was felt anteriorly to the trachea. A clear separation with the thyroid gland could not be made. A preoperative computed tomography (CT) scan of the neck revealed a calcified nodule on the midline, adjacent to the trachea (fig. 1⇓). Laboratory studies demonstrated a euthyroid status. Fig. 1.— Chest computed tomography scan. Internal scale bar=5 cm. During surgery, the nodule could not be separated from the tracheal cartilaginous ring and a left hemithyroidectomy, with resection of part of the affected cartilaginous ring, was carried out (histology of the nodule in fig. 2a⇓). The tracheal defect was closed with a muscle flap. The patient continued to do well on follow-up examinations ≤5 yrs postoperatively, without complaints. …

Positron emission tomography scintigraphy after thoracoscopic talcage

Accessible online at: www.karger.com/res A 60-year-old female patient presented at the hospital with left-sided chest pain and dry cough since a few days. In her past history, she had suffered from a rectal adenocarcinoma, diagnosed in 1992. She had been treated with surgery only. Laboratory findings were normal but chest X-ray showed an important left-sided pleural effusion. Thoracocentesis was performed and the cytological analysis of the fluid yielded the diagnosis of pleural metastasis of an adenocarcinoma. In search of the primary tumor site, various tests were done. Tumor markers (CEA, CA125, NSE), mammography, CT scan of the abdomen and CT scan of the thorax showed no signs of neoplasm. Colonoscopy with biopsies of the anastomosis was negative. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET scintigraphy) showed high FDG activity at the left lung apex and posterior of the aorta, suggesting malignancy at these sites (fig. 1). Because of recurrent and symptomatic pleural effusion, the patient was treated by thoracoscopic pleurodesis. Pleurodesis was obtained with 4 g of sterile asbestos-free talc, which was dispersed on the surfaces of the lung and parietal pleura. A chest tube connected with a water seal suction device was placed at the end of the procedure. After 2 days of suction and complete reexpansion of the left lung, the chest tube was removed. Since PET scintigraphy was the only abnormal imaging test, a follow-up scintigraphy was performed 3 months later (fig. 2). A diffuse and intense tracer activity was present around the whole left lung. This was interpreted to be the result of the inflammatory reaction caused by talc poudrage 3 months earlier. This hypothesis was confirmed by a third PET scintigraphy performed 6 months later showing an unchanged tracer image. There was no recurrence of pleural fluid. To our knowledge, this is the first FDGPET scintigraphy imaging of talc poudrageinduced pleural inflammation.

PRIMARY TRACHEOBRONCHIAL AMYLOIDOSIS: A SERIES OF 3 CASES

Abstract Primary tracheobronchial amyloidosis is a form of localized pulmonary amyloidosis, characterised by the deposition of AL-amyloid in trachea and bronchi. It is a rare and slowly progressive disease, usually requiring repeated endoscopic treatment. In this case series we describe symptoms, diagnostic and therapeutic procedures, radiological findings and pulmonary function testing in 3 cases of different presentation and severity. Two patients were treated by endoscopic debulking and stent placement during rigid bronchoscopy, both with excellent clinical and functional results. In one of these patients regular endoscopic and clinical control exams were performed in the 5 years following the initial treatment, showing stable disease, requiring no further therapeutic intervention until today.

Whole-lung lavage: a successful treatment for restoring acinar ventilation distribution in primary acquired pulmonary alveolar proteinosis.

A 51-year-old active smoker with primary acquired pulmonary alveolar proteinosis (PAP) diagnosed by biopsy and anti-GM-CSF antibodies was treated safely with whole-lung lavage (WLL). This resulted in a rapid improvement of symptoms and arterial blood oxygenation, but not of standard lung function parameters. However, we also performed the multiple-breath nitrogen washout (MBW) test to determine the lung clearance index (LCI) as well as indices of acinar ventilation heterogeneity (Sacin) and conductive ventilation heterogeneity (Scond). At baseline, a distinct abnormality was seen for Sacin and LCI, while Scond was at the upper limit of normal for this subject. Sacin, in particular, was in excess of the Sacin abnormality corresponding to a 20-pack-year smoking history. Immediately after WLL, Sacin and Scond both fell to within a normal range while LCI also decreased but remained abnormal. The Sacin decrease was much greater than the Scond decrease, which was to be expected after 1 week of smoking cessation at the hospital (smoking was resumed after release from hospital). A follow-up visit 7 weeks after WLL revealed a spectacular improvement on CT scan and improvements in standard lung function. Another follow-up visit 14 weeks after WLL showed further improvements in standard lung function, and both Sacin and Scond remained well within the normal range, and LCI was above the upper limit of normal. We conclude that in this patient, removal of excess surfactant by WLL resulted in a restored ventilation distribution in most of the distal air spaces.

Internal consistency of reference equations

To the Editors: In a recent European Respiratory Journal paper addressing the choice of reference values for spirometric indices, mean z-scores were used to quantify deviation from a large collated data set or to establish the absence of secular trends in forced expiratory volume in 1 s (FEV1) or forced vital capacity (FVC) [1]. Yet, once an appropriate set of reference equations is selected for use in any given laboratory, it is equally important to assess whether these equations are internally consistent, e.g. , in terms of age dependency of the various parameters under study. When consulting the most recent standardisation documents for guidance on the choice of reference equations [2, 3] the American Thoracic Society (ATS)/European Respiratory Society (ERS) Task Force literally states “currently this committee does not recommend any specific set of equations for use in Europe”. Due to our laboratory’s particular geographical location, we have thus far felt compelled to apply the European …